|
|
|||
|
| |||
|
| |||
|
| |||
|
|
|||
|
Amit Kumar Dutta, Ashok Chacko, Biju George, Joseph Anjilivelil Joseph, Department of Gastrointestinal Sciences, Christian Medical College & Hospital, Vellore 632 004, India Sukesh Chandran Nair, Department of Clinical Pathology, Christian Medical College & Hospital, Vellore 632 004, India Vikram Mathews, Department of Hematology, Christian Medical College & Hospital, Vellore 632 004, India Author contributions: Dutta AK, Chacko A, George B, and Joseph AJ were involved in patient care, data analysis, and writing up the paper; Mathews V conducted the mutations analyses; Nair SC estimated Protein C, S and, AT Ⅲ levels. Correspondence to: Dr. Ashok Chacko, MD, MNAMS (Gastro), DM, Professor & Head, Department of Gastrointestinal Sciences, Christian Medical College & Hospital, Vellore 632 004, India. gastro@cmcvellore.ac.in Telephone: +91-416-2282148 Fax: +91-416-2232035 Received: March 15, 2008 Revised: June 2, 2008 Accepted: June 9, 2008 Published online: July 28, 2008
Abstract AIM: To estimate the prevalence of inherited and acquired thrombophilic risk factors in patients with abdominal venous thrombosis and to compare the risk factor profiles between Budd-Chiari syndromes (BCS) and splanchnic vein thrombosis (SVT). METHODS: In this retrospective study, 36 patients with abdominal venous thrombosis were studied. The patients were divided into Budd-Chiari group (hepatic vein, IVC thrombosis) and splanchnic venous thrombosis group (portal, splenic, superior mesenteric veins) based on the veins involved. Hereditary and acquired thrombophilic risk factors were evaluated in all patients. RESULTS: Twenty patients had SVT, 14 had BCS, and 2 had mixed venous thrombosis. Ten patients (28%) had hereditary and 10 patients (28%) acquired thrombophilic risk factors. The acquired risk factors were significantly more common in the SVT group (SVT vs BCS: 45% vs 7%, c2 = 5.7, P = 0.02) while hereditary risk factors did not show significant differences between the two groups (SVT vs BCS: 25% vs 36%, c2 = 0.46, P = 0.7). Multiple risk factors were present in one (7%) patient with BCS and in 3 patients (15%) with SVT. No risk factors were identified in 57% of patients with BCS and in 45% of patients with SVT. CONCLUSION: Hereditary and acquired risk factors play an important role in the etiopathogenesis of abdominal venous thrombosis. Acquired risk factors are significantly more common in SVT patients while hereditary factors are similar in both groups.
© 2008 The WJG Press. All rights reserved.
Key words: Budd Chiari syndrome; Splanchnic vein thrombosis; Risk factors; Hereditary; Risk comparison
Peer reviewers: William Dickey, Altnagelvin Hospital, Londonderry, Northern Ireland BT47 6SB, United Kingdom; Ioannis E Koutroubakis, Assistant Professor, Ioannis Koutroubakis, Gastroenterology, University Hospital Heraklion, PO Box 01352 Heraklion, Crete 71110, Greece; Nikolaus Gassler, Professor, Institute of Pathology, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen 52074, Germany
Dutta AK, Chacko A, George B, Joseph JA, Nair SC, Mathews V. Risk factors of thrombosis in abdominal veins. World J Gastroenterol 2008; 14(28): 4518-4522 Available from: URL: http://www.wjgnet.com/1007-9327/14/4518.asp DOI: http://dx.doi.org/10.3748/wjg.14.4518
INTRODUCTION Abdominal venous thrombosis may present as Budd-Chiari Syndrome (BCS) (thrombosis of inferior vena cava and/or hepatic veins) or splanchnic venous thrombosis (SVT) (occlusion of portal, splenic, superior or inferior mesenteric veins). Hereditary and acquired risk factors have been implicated in the etiopathogenesis of abdominal venous thrombosis[1,2]. Hereditary risk factors for thrombophilia include Factor V Leiden gene mutation, prothrombin gene mutation, homozygous methyl tetrahydrofolate reductase (MTHFR) gene mutation, and deficiencies of coagulation inhibitor protein C, protein S and antithrombin Ⅲ (AT Ⅲ)[3-7]. Causes of acquired thrombophilia are myeloproliferative disorders, malignancy, surgery, antiphospholipid syndrome, pregnancy, oral contraceptives, and infection[8-11]. Identification of these risk factors may help in evaluation, planning therapy, or screening family members to evaluate an individual risk. There are few studies from South Asian regions which have comprehensively evaluated prothrombotic risk factors in BCS and portal venous thrombosis (PVT)[12,13]. These studies did not assess risk factors in patients with mesenteric venous thrombosis. Other studies have evaluated individual risk factors or multiple risk factors in single venous thrombosis[14-17]. The aim of the study was to analyse prothrombotic etiological profiles (hereditary and acquired) in patients with abdominal venous thrombosis and to compare the profiles of the BCS and SVT groups.
MATERIALS AND METHODS Patients admitted with abdominal venous thrombosis that had complete etiological work up during the period July 1997 to June 2006 were included in the study. Patients with incomplete evaluation (acute thrombosis or on anticoagulants) were excluded. Diagnosis of thrombosis was based on Doppler sonography, abdominal computed tomography (CT), or venography. For all selected patients, clinical information and laboratory data were collected by a standardized review of medical charts using uniform structured data forms. Details of acquired prothrombotic risk factors like abdominal surgery, oral contraceptives, pregnancy, liver cirrhosis, antiphospholipid syndrome, infection, or others were also obtained. Genetic tests for mutation in Factor V Leiden gene (1691, G-A), MTHFR gene (677 C-T), and prothrombin gene (20210, G-A) were done in all the patients by PCR amplification of the respective gene segments[18-20]. The amplified products were subjected to restriction digestion fragment length polymorphism (RFLP) analysis. Protein C and AT Ⅲ were assessed using chromogenic assays, done on the coagulation analyzer (Dade Behring’s Sysmex CA 1500). Free protein S was estimated by an immunoassay (Chromogenix Coamatic Protein S Free, IL) done on the ACL Advance (Instrumentation Laboratory). The assays for protein C, protein S, and AT Ⅲ were run concurrently with normal control and abnormal control (substrate present in low level simulating deficiency states) samples for validation as well as comparison with normal. The normal reference ranges of various tests were protein C: 50%-150% of normal; protein S: 50%-150% of normal; AT Ⅲ: 80%-120% of normal. Patients were considered to have protein C, protein S, or AT Ⅲ deficiency only if liver dysfunction was ruled out.
Statistical analysis Comparison between the BCS and the SVT group was done by Fischer’s exact test for categorical variables and Mann Whitney U test for continuous variables. A P value of < 0.05 was considered significant. All analysis was performed in SPSS for Windows Version 11.
RESULTS Thirty-six patients with thrombosis of abdominal veins were studied. The mean age of the patients was 36.7 years (range: 3-69 years). There were 24 males (67%) and 12 females (33%). Abdominal pain, the commonest symptom, was seen in 16 (44%), hepatomegaly in 4 (11%), splenomegaly in 10 (28%), and ascites in 13 (36%) patients. Acute presentation was more common in SVT (40%) than in BCS (21%). Diagnosis of abdominal venous thrombosis was made by Doppler sonography in 21 patients (58%), CECT abdomen in 10 (28%), and venography in 5 (14%) patients. Twenty patients had thrombosis of splanchnic veins (SVT), 14 had thrombosis of inferior vena cava and/or hepatic vein (BCS) and 2 had thrombosis in both splanchnic and IVC/hepatic veins. The site of thrombosis along with details of hereditary and acquired risk factors in all patients studied is shown in Table 1. Hereditary risk factors were present in 10 (28%) patients and acquired risk factors in 10 (28%) patients. The most common hereditary risk factors were Factor Ⅴ Leiden gene mutation (11%) and AT Ⅲ deficiency (11%) followed by protein C deficiency (8%). None of the patients had a prothrombin gene mutation, protein S deficiency, or was homozygous for MTHFR gene mutation. MTHFR mutation (heterozygous) was seen in 22% patients, which is not considered a risk factor for thrombosis. In the BCS group (14 patients): IVC obstruction alone was present in 5 patients, hepatic vein (HV) obstruction alone in 6 patients, and IVC + HV obstruction in 3 patients. Hereditary risk factors were present in 5 (36%) patients and acquired risk factor in one (7%) patient. In SVT group (20 patients): portal vein (PV) obstruction alone was present in 4 patients, splenic vein (SV) obstruction alone in 2 patients, superior mesenteric vein (SMV) obstruction alone in 1 patient, PV + SMV obstruction in 3 patients, and PV + SV + SMV obstruction in 10 patients. Hereditary risk factors were present in 5 (25%) patients and acquired risk factors in 9 (45%) patients. Comparison of risk factor profiles between the BCS and the SVT group is shown in Table 2. Hereditary risk factors were higher in the BCS group (BCS vs SVT: 36% vs 25%, P = 0.7), but this difference did not reach statistical significance. Acquired risk factors were significantly higher in the SVT group (SVT vs BCS: 45% vs 7%, P = 0.02). The prevalence of multiple risk factors in the BCS and the SVT group are shown in Table 3. More than one risk factor was seen in 1 (7%) patient in the BCS group and in 4 (20%) patients in the SVT group. No risk factor was identified in 57% of patients in the BCS group and in 45% of patients in the SVT group.
DISCUSSION This study evaluated hereditary and acquired risk factors in 36 patients with abdominal venous thrombosis. Hereditary risk factors were identified in 36% of patients with BCS and in 25% of patients with SVT. Acquired risk factors were detected in 7% of patients with BCS and in 45% of patients with SVT. Prevalence of Factor V Leiden mutation (FVLM), the most common cause of inherited thrombophilia, is variable in different populations[21]. Risk of venous thrombosis is 5- to 8-fold in heterozygotes and 50- to 80-fold in mutation homozygotes[3]. Janssen et al showed that prevalence of FVLM in BCS (26%) and PVT (8%) was higher than in controls (3%) suggesting that FVLM is an important risk factor for BCS (OR 11.3) and PVT (OR 2.7)[22]. Mohanty et al also found FVLM to be an important risk factor in BCS (26%; OR 14.5) and in PVT (6%; OR 2.3)[12]. Bhattacharyya et al demonstrated FVLM mutation in 17% of BCS and in 3% of patients with PVT[13]. Koshy et al showed that the prevalence of FVLM was similar in patients with PVT (3%) and controls (1%) and suggested that FVLM is not associated with PVT in India[14]. Similar observations were made by Sharma et al who demonstrated FVLM in 1.6% of patients with PVT and in 4% of controls[15]. In the present study, 14% of patients with BCS and 10% with SVT were heterozygotes, both higher than control data (1%-4%) reported earlier from India[12,14,15]. Though the numbers of patients in the study are small, results suggest that FVLM may be a risk factor in BCS and SVT. Prothrombin gene mutation, a risk factor for venous thrombosis (homozygote: 10-fold; heterozygote: 2- to 4-fold) is rare in African and Asian populations compared to Caucasians[23]. None of the five Indian studies have shown this gene mutation in cases or controls[12,13,15-17]. We also did not detect this mutation in any of our patients. Prevalence of heterozygote MTHFR gene mutation in patients with venous thrombosis is similar to healthy controls suggesting that this mutation is not an important prothrombotic factor[24]. It has been shown that homozygote MTHFR mutation, one of the causes of hyperhomocystinaemia (risk factor for vascular disease), is a risk factor for venous thrombosis[19,24]. None of the patients in the present study were homozygous for the MTHFR mutation. Three patients had heterozygote MTHFR mutation as the only abnormality. They were presumed to have idiopathic abdominal venous thrombosis as heterozygote MTHFR mutation alone is not considered a significant prothrombotic risk factor. Five heterozygous patients had additional hereditary or acquired risk factors. In a study from Northern India, Bhattacharyya et al investigated 57 BCS and 48 PVT patients, and reported none were homozygous for MTHFR gene mutation. Heterozygous mutations were seen in 24% of BCS and 21% of PVT patients[13]. Indian and Western studies have shown that protein C deficiency is the second most common cause of inherited thrombophilia in patients with BCS and PVT[12,13,22]. Amarapurkar et al showed that protein C deficiency was the commonest hereditary risk factor (26%) in a study on 28 patients with mesenteric venous thrombosis[25]. Protein C was also the commonest risk factor (38% patients) in a series of 16 patients with mesenteric venous thrombosis reported by Harward et al[26]. In the present study, protein C deficiency was demonstrated in 7% of patients with BCS and in 10% of patients with SVT. Prevalence of protein S, and AT Ⅲ deficiency as risk factors for inherited thrombophilia in patients with BCS and PVT were low in Indian and Western studies[12,13,22]. Protein S deficiency was not detected in any of our patients. AT Ⅲ deficiency was higher in patients with BCS (21%) as compared to those with SVT (5%). Diagnosis of inherited deficiencies of protein C, protein S, and AT Ⅲ, as a cause of abdominal venous thrombosis is difficult, because acquired deficiencies develop in liver failure, acute thrombosis, and during anticoagulant therapy[27]. None of the patients in the present study with protein C and AT Ⅲ deficiency had liver failure or were on anticoagulant therapy. Comparison of prothrombotic risk factor profiles between BCS and SVT showed a trend for hereditary risk factors to be more frequent in BCS (BCS vs SVT: 35.7% vs 25%; P = 0.7); two other Indian studies have made similar observations of hereditary factors being more frequent in BCS group compared to PVT group[12,13]. Studies on prevalence of acquired risk factors in abdominal venous thrombosis have shown variable results. Denninger et al and Janssen et al have shown that acquired risk factors are more frequent in PVT than in BCS[22,28]. Mohanty et al found the frequency of acquired risk factors to be similar in BCS and PVT[12]. In our study, acquired risk factors were significantly more common in the SVT group (BCS vs SVT: 7% vs 45%; P = 0.02) suggesting that SVT is a heterogeneous disease where hereditary and local risk factors play important roles. No risk factor was identified in 57% of BCS and 45% of patients with SVT. One possible reason may be the low prevalence of myeloproliferative disorders in our series (one patient). Myeloproliferative disorders (overt or latent) have been shown as an important risk factor in previous studies on abdominal vein thrombosis[28-31]. Tests for detecting latent myeloproliferative disorders (formation of spontaneous erythroid colonies in cultures of bone marrow progenitor cells in erythropoietin-poor medium[32,33]) were not performed on our patients. In a study from Western India, an etiological factor could be found in 59% of the BCS and 30% of the PVT patients[12]. Interestingly, in this study also, none had a myeloproliferative disorder. Previous studies have suggested that venous thrombosis results from coexistence of several risk factors[28]. In the present study, ≥ 2 risk factors were detected in 7% of BCS and in 20% of patients with SVT. Hereditary and acquired risk factors play an important role in etiopathogenesis of abdominal venous thrombosis. Acquired risk factors are significantly more common in patients with SVT while hereditary risk factors are similar in patients with BCS and SVT. Recognition and evaluation of these risk factors may help in therapy and prevention of disease progression. As a significant number of patients lack obvious etiology further research is required to identify as yet unrecognized risk factors.
COMMENTS Background Abdominal venous thrombosis may present as Budd-Chiari Syndrome (BCS) or splanchnic venous thrombosis (SVT). Hereditary and acquired risk factors are implicated in the etiopathogenesis of abdominal venous thrombosis. There are few systematic studies that have comprehensively evaluated both hereditary and acquired factors in BCS and SVT. Most studies have evaluated either a single prothrombotic risk factor or multiple risk factors in a single vein. Research frontiers Concept of multifactorial theory of thrombogenesis suggests that thrombosis occurs by activation of a trigger factor (acquired) in a thrombophilic milieu (hereditary). The prevalence of inherited risk factors is variable between populations throughout the world. Possible reasons are small numbers of patients studied, non-standardized evaluation of parameters tested, and genetic differences between patient populations. Data need to be generated by good studies from different geographical areas in the world. Etiological factors for abdominal venous thrombosis were identified in 70%-80% of patients in Western studies. In Indian studies, no risk factor was identified in half the patients suggesting that other unknown hereditary/risk factors may be operating in these patients. Innovations and breakthroughs The present study suggests that acquired risk factors which are preventable are important in etiopathagenesis of SVT. As no risk factors were identified in about half the patients, research needs to be ongoing to identify unknown hereditary/acquired risk factors operating in these patients. Applications Abdominal venous thrombosis is a life threatening condition caused by single or multiple, hereditary or acquired prothrombotic risk factors. Prevention and therapy with non-invasive techniques and new anticoagulant drugs are now possible. Complete thrombophilia screening is, therefore, important for risk assessment, and therapy in patients with abdominal venous thrombosis. With continuing search for hereditary risk factors (genetic molecular defects), true idiopathic thrombotic disease will become uncommon. Peer review This paper investigates genetic and acquired risk factors in patients with thromboembolism in abdominal veins. The authors make a difference between hereditary and acquired risk. It’s a nice study.
REFERENCES 1 Egesel T, Buyukasik Y, Dundar SV, Gurgey A, Kirazli S, Bayraktar Y. The role of natural anticoagulant deficiencies and factor V Leiden in the development of idiopathic portal vein thrombosis. J Clin Gastroenterol 2000; 30: 66-71 PubMed 2 Dilawari JB, Bambery P, Chawla Y, Kaur U, Bhusnurmath SR, Malhotra HS, Sood GK, Mitra SK, Khanna SK, Walia BS. Hepatic outflow obstruction (Budd-Chiari syndrome). Experience with 177 patients and a review of the literature. Medicine (Baltimore) 1994; 73: 21-36 PubMed DOI 3 Bayraktar Y, Harmanci O. Etiology and consequences of thrombosis in abdominal vessels. World J Gastroenterol 2006; 12: 1165-1174 PubMed 4 Deltenre P, Denninger MH, Hillaire S, Guillin MC, Casadevall N, Briere J, Erlinger S, Valla DC. Factor V Leiden related Budd-Chiari syndrome. Gut 2001; 48: 264-268 PubMed DOI 5 Margaglione M, Brancaccio V, Giuliani N, D'Andrea G, Cappucci G, Iannaccone L, Vecchione G, Grandone E, Di Minno G. Increased risk for venous thrombosis in carriers of the prothrombin G-->A20210 gene variant. Ann Intern Med 1998; 129: 89-93 PubMed 6 Pabinger I, Schneider B. Thrombotic risk in hereditary antithrombin III, protein C, or protein S deficiency. A cooperative, retrospective study. Gesellschaft fur Thrombose- und Hamostaseforschung (GTH) Study Group on Natural Inhibitors. Arterioscler Thromb Vasc Biol 1996; 16: 742-748 PubMed 7 Franco RF, Reitsma PH. Genetic risk factors of venous thrombosis. Hum Genet 2001; 109: 369-384 PubMed DOI 8 Espinosa G, Font J, Garcia-Pagan JC, Tassies D, Reverter JC, Gaig C, Cervantes F, Cervera R, Bosch J, Ingelmo M. Budd-Chiari syndrome secondary to antiphospholipid syndrome: clinical and immunologic characteristics of 43 patients. Medicine (Baltimore) 2001; 80: 345-354 PubMed DOI 9 Valla D, Le MG, Poynard T, Zucman N, Rueff B, Benhamou JP. Risk of hepatic vein thrombosis in relation to recent use of oral contraceptives. A case-control study. Gastroenterology 1986; 90: 807-811 PubMed 10 Walker ID. Thrombophilia in pregnancy. J Clin Pathol 2000; 53: 573-580 PubMed DOI 11 Matei D, Brenner B, Marder VJ. Acquired thrombophilic syndromes. Blood Rev 2001; 15: 31-48 PubMed DOI 12 Mohanty D, Shetty S, Ghosh K, Pawar A, Abraham P. Hereditary thrombophilia as a cause of Budd-Chiari syndrome: a study from Western India. Hepatology 2001; 34: 666-670 PubMed DOI 13 Bhattacharyya M, Makharia G, Kannan M, Ahmed RP, Gupta PK, Saxena R. Inherited prothrombotic defects in Budd- Chiari syndrome and portal vein thrombosis: a study from North India. Am J Clin Pathol 2004; 121: 844-847 PubMed 14 Koshy A, Jeyakumari M. Factor V Leiden is not commonly associated with idiopathic portal vein thrombosis in southern India. Indian J Gastroenterol 2006; 25: 140-142 PubMed 15 Sharma S, Kumar SI, Poddar U, Yachha SK, Aggarwal R. Factor V Leiden and prothrombin gene G20210A mutations are uncommon in portal vein thrombosis in India. Indian J Gastroenterol 2006; 25: 236-239 PubMed 16 Koshy A, Jeyakumari M. Prothrombin G20210A gene variant is not associated with idiopathic portal vein thrombosis in an area endemic for portal vein thrombosis. Ann Hematol 2006; 85: 126-128 PubMed DOI 17 Kumar SI, Kumar A, Srivastava S, Saraswat VA, Aggarwal R. Low frequency of factor V Leiden and prothrombin G20210A mutations in patients with hepatic venous outflow tract obstruction in northern India: a case-control study. Indian J Gastroenterol 2005; 24: 211-215 PubMed 18 Bertina RM, Koeleman BP, Koster T, Rosendaal FR, Dirven RJ, de Ronde H, van der Velden PA, Reitsma PH. Mutation in blood coagulation factor V associated with resistance to activated protein C. Nature 1994; 369: 64-67 PubMed DOI 19 Frosst P, Blom HJ, Milos R, Goyette P, Sheppard CA, Matthews RG, Boers GJ, den Heijer M, Kluijtmans LA, van den Heuvel LP. A candidate genetic risk factor for vascular disease: a common mutation in methylenetetrahydrofolate reductase. Nat Genet 1995; 10: 111-113 PubMed DOI 20 Poort SR, Rosendaal FR, Reitsma PH, Bertina RM. A common genetic variation in the 3'-untranslated region of the prothrombin gene is associated with elevated plasma prothrombin levels and an increase in venous thrombosis. Blood 1996; 88: 3698-3703 PubMed 21 Lucotte G, Mercier G. Population genetics of factor V Leiden in Europe. Blood Cells Mol Dis 2001; 27: 362-367 22 Janssen HL, Meinardi JR, Vleggaar FP, van Uum SH, Haagsma EB, van Der Meer FJ, van Hattum J, Chamuleau RA, Adang RP, Vandenbroucke JP, van Hoek B, Rosendaal FR. Factor V Leiden mutation, prothrombin gene mutation, and deficiencies in coagulation inhibitors associated with Budd-Chiari syndrome and portal vein thrombosis: results of a case- control study. Blood 2000; 96: 2364-2368 PubMed 23 Rosendaal FR, Doggen CJ, Zivelin A, Arruda VR, Aiach M, Siscovick DS, Hillarp A, Watzke HH, Bernardi F, Cumming AM, Preston FE, Reitsma PH. Geographic distribution of the 20210 G to A prothrombin variant. Thromb Haemost 1998; 79: 706-708 PubMed 24 Li XM, Wei YF, Hao HL, Hao YB, He LS, Li JD, Mei B, Wang SY, Wang C, Wang JX, Zhu JZ, Liang JQ. Hyperhomocysteinemia and the MTHFR C677T mutation in Budd-Chiari syndrome. Am J Hematol 2002; 71: 11-14 25 Amarapurkar DN, Patel ND, Jatania J. Primary mesenteric venous thrombosis: a study from western India. Indian J Gastroenterol 2007; 26: 113-117 PubMed 26 Harward TR, Green D, Bergan JJ, Rizzo RJ, Yao JS. Mesenteric venous thrombosis. J Vasc Surg 1989; 9: 328-333 27 Tripodi A, Mannucci PM. Abnormalities of hemostasis in chronic liver disease: reappraisal of their clinical significance and need for clinical and laboratory research. J Hepatol 2007; 46: 727-733 PubMed DOI 28 Denninger MH, Chait Y, Casadevall N, Hillaire S, Guillin MC, Bezeaud A, Erlinger S, Briere J, Valla D. Cause of portal or hepatic venous thrombosis in adults: the role of multiple concurrent factors. Hepatology 2000; 31: 587-591 PubMed 29 Valla D, Casadevall N, Lacombe C, Varet B, Goldwasser E, Franco D, Maillard JN, Pariente EA, Leporrier M, Rueff B. Primary myeloproliferative disorder and hepatic vein thrombosis. A prospective study of erythroid colony formation in vitro in 20 patients with Budd-Chiari syndrome. Ann Intern Med 1985; 103: 329-334 PubMed 30 De Stefano V, Teofili L, Leone G, Michiels JJ. Spontaneous erythroid colony formation as the clue to an underlying myeloproliferative disorder in patients with Budd-Chiari syndrome or portal vein thrombosis. Semin Thromb Hemost 1997; 23: 411-418 PubMed 31 Valla D, Casadevall N, Huisse MG, Tulliez M, Grange JD, Muller O, Binda T, Varet B, Rueff B, Benhamou JP. Etiology of portal vein thrombosis in adults. A prospective evaluation of primary myeloproliferative disorders. Gastroenterology 1988; 94: 1063-1069 PubMed 32 Pagliuca A, Mufti GJ, Janossa-Tahernia M, Eridani S, Westwood NB, Thumpston J, Sawyer B, Sturgess R, Williams R. In vitro colony culture and chromosomal studies in hepatic and portal vein thrombosis--possible evidence of an occult myeloproliferative state. Q J Med 1990; 76: 981-989 PubMed 33 Hirshberg B, Shouval D, Fibach E, Friedman G, Ben-Yehuda D. Flow cytometric analysis of autonomous growth of erythroid precursors in liquid culture detects occult polycythemia vera in the Budd-Chiari syndrome. J Hepatol 2000; 32:
S- Editor Li DL L- Editor Mihm S E- Editor Lin YP
| |||
|
|
PubMed